Patient Safety / Quality

Speak to be heard: Effective nurse advocacy

Advocacy means using one’s position to support, protect, or speak out for the rights and interests of another. Nurses have long claimed patient advocacy as fundamental to their practice. The American Nurses Association’s Code of Ethics for Nurses and Scope and Standards of Nursing Practice clearly identify nurses’ ethical and professional responsibility for protecting the safety and rights of their patients. State nursing practice acts may establish a legal duty for patient advocacy as well.

Why must nurses advocate?

Patient safety depends on nurse advocacy. Over 10 years ago, the Institute of Medicine (IOM) shocked the nation when it reported in To Err is Human: Building a Safer Health System that an amazing 100,000 deaths each year were attributable to medical errors. In 2004, the IOM report Keeping Patients Safe: Transforming the Work Environment of Nurses highlighted the critical role of nurses in safety efforts and challenged organizations to design work environments in which nurses can provide safe care.

Nurses are at the “sharp end” of errors in health care. Because of their proximity and continuity with patients, nurses are often the last opportunity to prevent an error—to spot a mislabeled I.V. bag before it’s infused, to recognize that a patient’s allergy band doesn’t match the medication administration record, to identify slight changes in a patient’s condition that could signal a significant complication.

Keeping Patients Safe urged the establishment of “cultures of safety” within healthcare organizations to achieve safe practice environments. An organization committed to a culture of safety makes safety an explicit priority and responsibility shared by every individual at every level of the organization. Everyone is expected to participate in identifying and resolving safety issues.

Nurse advocacy challenges

Direct-care nurses are poised especially well to identify and speak up about conditions that may result in near misses or actual adverse events. Cultures of safety promote and encourage staff to raise issues, yet most workplace cultures are imperfect and nurses may face challenges in their advocacy efforts. For example:

Nurses may lack communication skills to clearly articulate their concerns in such a manner that others are able to respond. A nurse who complains that “staffing is always unsafe” leaves a supervisor in a poor position to respond. However, by specifically describing the nature of the concern—for example, “I’m concerned that our planned staffing didn’t account for an ICU patient being transferred in and two additional patients being admitted from the ED. How can we adjust to accommodate these changes?”—the problem and potential solutions become clearer.


Nurses may be uncertain about how to address an issue. Reporting structures may vary depending on the issue: a physician who fails to respond adequately to a patient issue at 2:00 A.M.; chronically late medication delivery from the pharmacy; a medical device that repeatedly fails during patient use. The chain of command through departments (risk management, corporate compliance, medical staff) or individuals (direct supervisors, the chief nursing officer) may not be well established. Further, nurses, especially those in direct-care roles, may not be adept at negotiating the inherent power gradients in healthcare organizations.

Nurses may fear retaliation and lack knowledge about established processes and protections for patient advocacy activities. Raising a concern disrupts the status quo and challenges the organization to confront problems. If identifying concerns or opportunities for improvement is viewed as complaining, those raising concerns may be labeled “troublemakers.”

One of the most egregious examples of retaliation for patient advocacy activities occurred recently in Winkler County, Texas, when two nurses, Vickilyn Galle and Anne Mitchell, were criminally indicted by the county attorney for reporting a physician to the Texas Medical Board because of patient-safety concerns. One week before trial, charges against Galle were dropped. A jury found Mitchell not guilty. Subsequently, the Texas Medical Board took action against the physician for witness intimidation as well as practice violations. Further, the Texas Attorney General’s office indicted the hospital administrator, Winkler County sheriff, county prosecutor, and physician for retaliation and other charges. (See www.texasnurses.org for more information.)

Nurses may have limited opportunities to advocate proactively in organizations lacking shared decision-making processes. Decision-making opportunities concerning patient care include performance-improvement activities, staffing committees, and product evaluation teams. This is a missed opportunity for improving safety.

The nurse’s duty to patient safety is well established and is reflected in the nurse’s role of patient advocate. The value of patient advocacy in supporting an organizational culture of safety isn’t always appreciated, yet the knowledge and response to nursing concerns about patient safety can make a powerful contribution to patient outcomes.

Speak to be heard

Nurses in all roles and at all levels of the organization have a duty to patient safety, although each may have different circles of influence. To be effective in advocacy efforts, nurses first need to understand the laws and regulations governing their practice. For example, the Texas Nursing Practice Act (NPA) has specific provisions to protect nurses who raise concerns about patient safety. It’s illegal to retaliate against a nurse who reports a licensed healthcare practitioner, agency, or facility to a licensing board (such as the Texas Department of Aging and Disability Services, which licenses nursing homes), to an accrediting agency (such as The Joint Commission), or internally (within the facility) because he or she believes they have exposed a patient to a substantial risk of harm. Another provision in the Texas NPA protects nurses who report staffing concerns to nurse staffing committees, who are then responsible for evaluating and responding to the concern. A unique provision in Texas, called Safe Harbor, provides an avenue for resolving situations in which a nurse believes an assignment or directive may violate his or her duty to the patient. (See Safe Harbor.) Nurses who understand their state practice acts are best able to use established processes to advocate effectively for their patients while protecting themselves from retaliation and from violations against their license.

Safe Harbor

Texas nurses who make or accept assignments must consider patient safety. But there are times when nurses may differ in their assessment of what is “safe.” Nurses who believe that requested conduct, such as an assignment or a specific directive, may violate their duty to the patient may invoke “Safe Harbor.” Safe Harbor provides for resolution of the question of safety through a Nursing Peer Review Committee (NPRC). The nurse may accept the assignment and be protected from retaliation from the employer and disciplinary action from the board of nursing pending the committee’s decision. The committee must make a determination within 14 days of the request. Unfortunately, some organizations discourage Safe Harbor requests and some nurses lack the knowledge to use the process effectively. An effective incident of a Safe Harbor request is described below.

A long-term care facility reduced staffing from three full-time wound care nurses to one. Two weeks later, the remaining wound care nurse noted an increased occurrence of pressure ulcers among the residents and believed this was related to her inability to complete her assignment of skin assessments and wound care treatments. She believed her duty to patient safety was compromised by the increased workload and she invoked Safe Harbor. She continued in her role as the single wound care nurse for the facility until the NPRC met. The NPRC determined that her assignment did violate her duty to protect the residents. The director of nursing accepted the committee’s decision and adjusted the assignment by adding a part-time wound care nurse and assigning charge nurses to assist with skin assessments.

The same holds true for organizational policies and procedures. Nurses who understand how and where to report concerns, especially how to access the chain of command when they don’t receive an acceptable response, will be most effective in achieving positive outcomes for their patients. Skill in communicating concerns specifically and objectively will facilitate problem solving. The goal of communication is understanding and being understood. The SBAR (Situation, Background, Assessment, Response) technique has been adopted by many organizations as a tool for framing communication to accomplish mutual understanding about patient care as well as organizational or process issues. Nurses need to be able to articulate their concerns in a manner that invites an effective response. (See SBAR communication example.)

SBAR communication example

Finally, nurses can contribute to patient safety and a positive practice environment that benefits both nurses and patients by actively participating in organizational improvement efforts. In the appendices of The Future of Nursing: Leading Change, Advancing Health, Donald Berwick writes:

Present steadily at the point of care, committed to excellence and reliability, equipped to measure locally, biased toward teamwork, and, crucially, encouraged to innovate locally to adapt to changes in local contexts, nurses proved the ideal leaders for changing care systems and raising the bar on results.

Berwick argues that all nurses must become “improvers,” all nurses must think about ways to improve their work and the care and safety of patients. Perhaps this is advocacy at its best—proactive behavior that works to improve and correct rather than report once something has gone wrong.

By virtue of their formal power, nurse administrators are in a position to influence movement toward organizational cultures of safety and zero tolerance for retaliation when nurses raise patient-safety concerns. Nurses in leadership roles can acknowledge uneven power distribution in organizations and ensure that an effective chain-of-command structure exists. Policies and procedures should adhere to the intent as well as the word of laws and regulations and be clearly communicated so nursing staff understand how and where to raise concerns. Nurse leaders, especially front-line managers, can coach staff to articulate concerns using established channels, reinforce a culture of safety by encouraging staff to speak up, and promptly respond to and follow up with staff who raise concerns. Finally, participatory management structures and shared decision-making processes support proactive behaviors to improve care processes and prevent problems.

An organization that is serious about patient safety desires information about situations that threaten patient safety, such as incidents of short staffing, malfunctioning equipment, questionable clinical practices, and near misses. As Donald Berwick stated, nurses are the “ideal leaders” for improving patient safety. To lead, nurses must speak out or advocate. After all, it’s our duty.

When this article was written Cindy Zolnierek was director of practice for the Texas Nurses Association, Austin. She is currently assistant professor at Texas State University, San Marcos.

Selected references

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association; 2001.

American Nurses Association. Nursing: Scope and Standards of Practice. Silver Spring, MD: American Nurses Association; 2010.

Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-175.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.

Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.

Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.

Texas Board of Nursing. http://www.bon.texas.gov/.

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One thought on “Speak to be heard: Effective nurse advocacy”

  1. ANN says:

    I’m very astonished with this disclosure,, because in Mexico, we are thousands years far away to get something like that.

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